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					                              Health, Education and Social Protection Division
                              Supra-regional Project “AIDS-Control in Developing Countries”
GTZ HIV Practice Collection

                                                Bringing the
                                                AIDS Response Home
                                                Empowering District and Local
                                                Authorities in Lesotho, Tanzania and
                                                Mpumalanga, South Africa
    Table of Contents

    Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             2
    The GTZ HIV Practice Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  3
    Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .            4
    Bringing the AIDS Response Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                      5
           At the epicentre of the global AIDS epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            5
           Building the global response to AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                        5
           Building each country’s response to AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          6
           Why strong district and local AIDS responses are essential . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                  7
           GTZ’s commitment to district and local mainstreaming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                  7
    In Lesotho, Making Community Councils the Gateways to Fighting AIDS . . . . . . . . . . . . . . . . . . . . . . . .                                          8
           The context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         8
           GTZ support to Lesotho’s AIDS response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            9
           The Gateway Approach to empowering Community Councils . . . . . . . . . . . . . . . . . . . . . . . . . . .                                           9
           2006 and beyond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .              11
    In Tanzania, District and Ward Empowerment through Capacity Building . . . . . . . . . . . . . . . . . . . . . . . .                                        13
           The context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        13
           Training Council and Ward Multisectoral AIDS Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                    14
           The results, assessed one year later . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                     19
    In Mpumalanga, Mainstreaming AIDS in Provincial, District and Local Government . . . . . . . . . . . . . . . .                                              21
           The context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        21
           Mainstreaming in Mpumalanga Rural Development Programme . . . . . . . . . . . . . . . . . . . . . . . . .                                            22
           Mainstreaming in provincial government departments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                 22
           Mainstreaming in district and local government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                           24
           Results and the way forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  25
    Drawing Lessons from Lesotho, Tanzania and Mpumalanga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                   26
           Achievements, so far . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             26
           The main challenges and some ways of meeting them . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                    26
           Learning but adapting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .              27
    Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    29
    Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     30
    Impressum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     30
    Toolbox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   31

    GTZ would like to thank everyone involved in the activities described in this report and in its preparation.
    In addition to the GTZ experts of the three projects and the writer (see page 35) these are:
    • The Governments of the Kingdom of Lesotho, United Republic of Tanzania and Province of Mpumalanga
      (Republic of South Africa) and the Tanzania Commission for AIDS (TACAIDS).
    • The political leaders and staff of many national and provincial ministries and district and local authorities,
      traditional leaders, representatives from civil society organizations and faith-based organizations, and
      herd-boys in Lesotho.
    • Anna von Roenne, EPOS/GTZ, as Secretary of the GTZ HIV Peer Review Group, who coordinated the
      editorial process and Bob Verbruggen, UNAIDS, and Andrea Milkowski, GTZ, members of the Peer
      Review Group, for reviewing and commenting on drafts.

    Title photo: CMAC members from different councils participating in a refresher training for writing fundable proposals, September 2004
The GTZ HIV Practice Collection

The GTZ HIV Practice Collection aims to facilitate         The PRG strives for a balanced composition in
ongoing learning and exchange between colleagues      terms of gender, regions and HIV-related qualifica-
from GTZ and other organisations in the field of      tions and experiences. It is open for new members
development cooperation about successes and           with professional experience in HIV-related work
challenges encountered in their responses to the      and with an interest in the joint review of innova-
HIV pandemic.                                         tive approaches developed by GTZ and its partner
     The collection is edited by the GTZ HIV Peer          All submissions to the GTZ HIV Practice
Review Group (PRG), which was established in          Collection are peer-reviewed in relation to a set of
September 2004. Its Secretariat is run by the         jointly defined criteria (see box).While some of
supraregional GTZ project “AIDS Control in            the documented practices cannot fully meet, as
Developing Countries”. PRG members comprise           yet, the criteria for “Good Practice” (i.e. several
colleagues from GTZ projects around the world,        external evaluations and multiple replications in
from head office Germany, as well as representati-    different countries), all of them represent exam-
ves of UNAIDS,WHO, of other German organisa-          ples of “Promising Practice” that may inform and
tions and of a network of organisations of people     inspire other actors in the complex and dynamic
living with HIV.                                      field of HIV prevention, impact mitigation and
     By jointly evaluating selected approaches in a   care and support for those affected by HIV and
transparent peer review process, the PRG repre-       AIDS.
sents collaborative knowlegde management that              Twenty years into the epidemic,AIDS experts
involves HIV experts from different contexts          and activists worldwide are continuing to look for
around the world in an ongoing discussion about       practicable and cost-effective interventions geared
effective interventions.The resulting documenta-      to different regional and cultural contexts and to
tions provide project managers and their partner      the needs and realities of the people they work
organisations with a range of innovative and tested   with.With this collection, GTZ is contributing to
approaches that can be adapted to different local     these efforts.

  Selection Criteria
  • Effectiveness
  • Transferability
  • Participatory and empowering approach
  • Gender awareness
  • Quality of monitoring and evaluation
  • Innovation
  • Comparative cost-effectiveness
  • Sustainability

    Executive Summary

    While the latest estimates indicate the AIDS                In a number of countries in sub-Saharan
    epidemic is declining in two of the 50 sub-Saharan     Africa, GTZ works in partnership with national,
    African countries and stabilizing in many others,      provincial, district and local governments commit-
    the prevalence rates and number of new infec-          ted to “bringing the AIDS response home” by main-
    tions per year are still at extremely high levels.     streaming the AIDS response into the activities of
    Due to AIDS, some countries have seen their            district and local government.This involves buil-
    average life expectancies cut nearly in half and       ding district and local government capacity to
    are experiencing development reversal for the          respond by providing training and follow-up, inclu-
    first time in their histories. In addition, there is   ding technical support to AIDS-related activities.
    alarming new evidence that, in some countries,              This report describes how, with GTZ’s tech-
    young women are several times as likely as             nical support, the Kingdom of Lesotho, the
    young men to become infected with HIV.                 United Republic of Tanzania and the Province of
                                                           Mpumalanga in the Republic of South Africa have
    In 2001, the UN General Assembly’s Declaration of      been empowering districts and localities to
    Commitment on HIV/AIDS called on bilateral and         respond to AIDS. The approach, in all three cases,
    multilateral institutions to provide substantially     has been learn-as-you go. Methods and tools are
    increased financial and technical support to deve-     developed and applied and, then, when they do
    loping countries as they scale up their responses      not work as well as hoped, they are refined or
    to AIDS as quickly as possible. It called for main-    replaced with new methods and tools.The processes
    streaming of AIDS policies and programmes into         of empowerment are ongoing.While it is too
    all national development instruments and all sec-      early to tell what the long-term results will be, the
    tors of government and the economy.At the 2005         immediate results have been impressive. They
    World Summit and again at the 2006 High Level          include strategies and mechanisms that are stream-
    Meeting on AIDS, the UN General Assembly re-           lining the flow of available money to the front lines
    affirmed the Declaration of Commitment and             and putting it to work where it is most needed.
    resolved to aim for universal access to prevention,         With this publication and the accompanying
    treatment, care and support by 2010.                   toolbox (on CD-ROM), GTZ shares lessons learned
         GTZ notes that urban neighbourhoods and           and methods and tools used in Lesotho,Tanzania,
    rural communities have always been at the front        Mpumalanga and invites readers to use and adapt
    lines of the epidemic, since they are where the        them in whatever ways may be appropriate for
    people infected with and affected by HIV live and      other settings.
    where prevention, treatment, care, support, and
    impact mitigation can be delivered to those people.
                                                             The results also include methods and tools –
                                                             marked in the text with this symbol    – that
                                                             can be adapted for use in other countries,
                                                             provinces, districts and localities.

Bringing the AIDS Response Home

At the epicentre of the global AIDS                                       Building the global response to AIDS
epidemic                                                                  AIDS emerged as a new disease in 1981 and its
In 2005, the 50 countries of sub-Saharan Africa                           primary cause, HIV, was discovered a year later.As
accounted for 11% of the world’s total population                         the AIDS epidemic spread from country to country,
but 64% (almost two-thirds) of the world’s total                          the general public and their political leaders were
number of people living with HIV.An estimated                             slow to respond. Facing up to the facts was difficult
24.5 million sub-Saharan Africans were living with                        because HIV is transmitted through sexual and
HIV and an estimated 2.7 million became newly                             other activities that are sometimes illegal, strictly
infected that year, while an estimated 2.0 million                        taboo or widely disapproved or that are simply
died of AIDS.The epicentre of the global AIDS                             considered too personal and embarrassing to be
epidemic continued to be in the southern part                             discussed in public, even if widely practiced in
of sub-Saharan Africa. The 10 countries with the                          private.The first cries for a response usually came
world’s highest rates of HIV prevalence among                             from people infected with HIV or at high risk of
adults 15-49 years old – ranging from 10.7% to                            infection, their families and friends, and advocacy
33.4% – included all five countries of the Southern                       groups they established or that took up their
Africa sub-region, the four southernmost countries                        cause. The first and most vigorous response usually
of the Eastern Africa sub-region and the southern-                        came from within their own neighbourhoods and
most country of the Middle Africa sub-region1.                            communities – from the clinics, hospitals, social
     While the latest estimates indicate that the                         service agencies, and formal or informal care and
epidemic is declining in two sub-Saharan countries                        support networks located there.
– due to successful prevention but also due to the
deaths of so many infected people – and stabiliz-
ing in others, the prevalence rates and the numbers
of new infections each year are still at extremely
high levels. In addition, there is alarming new evi-
dence that young women are continuing to become
infected at very much higher rates than young
men. Estimates based on an extensive household
survey are that, among 15-24 year-olds in South
Africa, the rate of new infection during 2005 was
0.8% among males but 6.3% (nearly 8 times higher)
among females2.

1 UNAIDS (2006). 2006 Report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS.                           5
2 HRSC (2005). South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey. Johannesburg, Nelson Mandela
  Foundation (NMF) and Human Sciences Research Council (HSRC) of South Africa.
         As the epidemic continued to spread year                               support and many different country-level partners
    after year, it showed no signs of reaching the plate-                       had reached no mutual agreement on strategies or
    au that epidemics normally reach in just a few                              mechanisms for coordinating and monitoring and
    months or years before they begin to decline.                               evaluating their activities.
    Clearly,AIDS was an exceptional disease that cal-                                In April 2004, at the Consultation on
    led for an exceptional response. In September                               Harmonization of International AIDS Funding,
    2000, the UN Millennium Summit established 8                                representatives from developing countries, bilate-
    Millennium Development Goals and one was to                                 ral and multilateral institutions and other interna-
    combat AIDS, with the target of halting and revers-                         tional partners endorsed the “Three Ones” prin-
    ing the epidemic by 2015.3 In June 2001, a Special                          ciples to guide each country’s response: one AIDS
    Session of the UN General Assembly followed up                              framework, one AIDS coordinating authority and
    with the Declaration of Commitment on HIV/AIDS,                             one AIDS monitoring and evaluation system. In
    which commits donor countries (acting bilaterally                           March 2005, a follow-up meeting reviewed pro-
    and through multilateral institutions) to providing                         gress and established a Global Task Team that
    developing countries with substantial increases in                          recommended a number of ways that multilateral
    financial and technical support as they take urgent                         institutions could provide more effective support
    action to scale up their responses to AIDS.4                                to countries in order to accelerate progress on
         At the 2005 World Summit5 and the 2006 High                            implementing the “Three Ones” and progress
    Level Meeting on AIDS, the UN General Assembly                              toward universal access to prevention, treatment,
    reviewed progress on the Millennium Development                             care and support.8
    Goals and the Declaration of Commitment on
    HIV/AIDS and agreed to aim “towards the goal of                             Mainstreaming AIDS in all sectors,
    universal access to comprehensive prevention pro-                           at all levels
    grammes, treatment, care and support by 2010.” 6                            Arising from the Global Task Team’s recommen-
                                                                                dations, the 2006-2007 Consolidated UN Technical
    Building each country’s response to AIDS                                    Support Plan9 and UNAIDS Technical Support
    The Declaration of Commitment on HIV/AIDS                                   Division of Labour10 designate UNDP as the lead
    called on developing countries to “integrate                                UN-system partner on “development, governance
    HIV/AIDS prevention, care, treatment and support                            and mainstreaming” and the ILO, UNAIDS
    and impact mitigation priorities into the main-                             Secretariat, UNESCO, UNFPA, UNHCR, UNICEF,
    stream of development planning, including in                                WHO, and World Bank as the other main UN-
    poverty eradication strategies, national budget                             system partners. An implementation guide for
    allocations and sectoral development plans.”7 For                           countries defines “mainstreaming” as:
    the sake of brevity, such integration is often refer-
    red to as “mainstreaming AIDS.”As financial sup-                                  ‘a process that enables all development
    port for the response increased, however, it beca-                                actors to address the causes and effects
    me evident that there was far too much duplica-                                   of AIDS in an effective and sustained
    tion and waste and there were major gaps in the                                   manner, both through their usual work
    overall response in each country. Many different                                  and within their workplaces.’ 11
    bilateral and multilateral institutions had their own
    mechanisms for allocating money and technical

    3 United Nations (2000). United Nations Millennium Declaration: United Nations General Assembly, 55th session, 6 September 2000. New York: United
    4 United Nations (2001). Declaration of Commitment on HIV/AIDS: United Nations General Assembly, special session on HIV/AIDS, 25-27 June 2001.
      New York, United Nations.
6   5 United Nations (2005 ). 2005 World Summit Outcome. New York, United Nations.
    6 United Nations (2006). Draft Political Declaration, 2 June 2006. New York, United Nations.
    7 UN (2001). Declaration of Commitment on HIV/AIDS: United Nations General Assembly, special session on HIV/AIDS, 25-27 June 2001. New York,
      United Nations Department of Public Information and UNAIDS.
    8 UNAIDS (2006). 2006 Report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS.
    9 UNAIDS (2005). The 2006-2007 Consolidated Technical Support Plan for AIDS. Geneva, Joint Programme on HIV/AIDS.
    10 UNAIDS (2005). UNAIDS Technical Support Division of Labour: Summary and & Rationale. Geneva, Joint United Nations Programme on HIV/AIDS.
     The development actors or partners within
countries include (or potentially include) national,
district and local governments and all of their
ministries, departments, divisions, and agencies
and also include groups and networks of people
living with HIV, civil society organizations, and
private businesses and industries at the national,
provincial, district and local levels. Mainstreaming
mobilizes them and enables them to:
                                                                             Mainstreaming AIDS in the work and work-
• Understand the causes and effects of HIV, espe-                        places of multiple partners, across all sectors at
  cially as related to their usual work and their                        the national, provincial, district and local levels is
  workplaces                                                             an effective way of:

• Determine how they might address the causes                            • Harnessing the competences and resources of all
  and effects, taking advantage of any comparative                         public, private and civil society partners with po-
  advantages they may have                                                 tential to contribute to a country’s AIDS response

• Work with others to coordinate efforts, pool                           • Addressing the structural and systemic causes of
  resources and add value to their own efforts –                           vulnerability to HIV – for example, the vulnerabi-
  for example, support a civil society organization                        lity of girls to infection because they are subject
  by giving it the contract to develop and deliver                         to sexual exploitation and assault in schools and
  a workplace programme on HIV.                                            on the way to and from schools

                                                                         • Enhancing the sustainability of the AIDS response
                                                                           by embedding it in the policies and programmes
                                                                           of many different partners, so the weaknesses or
                                                                           failures of a few partners are not so damaging

                                                                         • Turning AIDS from a development challenge to
                                                                           a development opportunity by adding to the
                                                                           resources and improving the performance of
                                                                           partners.This mean that they are more able to
                                                                           contribute not only to the AIDS response also to
                                                                           responses to the other development issues they
                                                                           address is the normal course of doing their work.12

11 UNDP, UNAIDS, World Bank (2005). Mainstreaming HIV and AIDS in sectors and programmes: an implementation guide for National responses. New
   York, Geneva, Washington, Joint United Nations Programme on HIV/AIDS, United Nations Development Programme and World Bank.
12 Adapted with permission from "Mainstreaming AIDS in Development: Why and How to Do It", UNAIDS/UNDP/WB (2006)

    Why strong district and local AIDS                                         GTZ’s commitment to district and
    responses are essential                                                    local mainstreaming
    In most countries, the first response to AIDS                              The German Technical Cooperation Agency or
    comes from within the neighbourhoods and com-                              Deutsche Gesellschaft für Technische Zusam-
    munities where the epidemic emerges and begins                             menarbeit (GTZ), a government-owned company,
    to spread.The front lines of the epidemic remain                           supports some 2700 development projects and
    in just these places where HIV prevention, care,                           programmes in more than 130 countries, has
    treatment and support and impact mitigation are                            offices in half of those countries and employs
    delivered to the people who need them.While                                some 10,000 people, of whom more than 8,000
    national strategies, coordinating mechanisms and                           are citizens of the countries in which the projects
    monitoring and evaluation systems are essential                            and programmes are located.
    they must reach down to the district and local                                  In early 2003, GTZ launched a worldwide
    levels and both support and be supported by                                HIV workplace programme to serve all of its own
    district and local strategies, coordinating mecha-                         employees and their families. In addition, it requires
    nisms and inputs to monitoring and evaluation.                             the mainstreaming of AIDS into all of its work in
         In 1999, the mayors and municipal leaders                             sub-Saharan Africa.The GTZ Africa department has
    from ten sub-Saharan African countries launched                            fully implemented the two pillars on which effec-
    the Alliance of Mayors and Municipal Leaders on                            tive mainstreaming rests: 1) a comprehensive
    HIV/AIDS in Africa, which now has chapters in 13                           workplace programme for its own employees and
    countries. In those countries and others, national                         2) contributions to the AIDS response that are
    AIDS authorities have come to recognize district                           consistent with GTZ’s expertise and responsibili-
    and local governments as key partners.13 They are                          ties in all its development projects and program-
    closer to the front lines of the AIDS epidemic than                        mes.To support its project and programme mana-
    national governments and they are better-placed                            gers, GTZ has produced a toolbox called “Main-
    to understand unique local circumstances, needs,                           streaming HIV/AIDS: How we do it.”14 It describes
    social structures, attitudes, and traditions. They can                     and provides background documentation on
    apply such understanding in the search for the                             GTZ’s mainstreaming activities in different sectors.
    most appropriate and practical solutions to the                                 Many of the projects and programmes suppor-
    problems – pervasive in sub-Saharan Africa – of                            ted by GTZ are in partnership with national, pro-
    severely limited infrastructure and human resour-                          vincial, district and local governments and commit-
    ces in public health, social and other services.                           ted to building district and local capacity to
         At the same time, district and local govern-                          respond to AIDS.The following chapters describe
    ments usually lack the financial and technical                             three examples of GTZ-supported district and
    capacity – i.e., qualified staff or access to technical                    local capacity-building in sub-Saharan Africa.
    support – enabling them to mount effective
    responses to AIDS. For this reason, it is essential
    that mainstreaming reach down to their levels.

8   13 See the Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa (AMICALL) web site at:
    14 GTZ (2005). Comprehensive Toolkit: "Mainstreaming HIV/AIDS: How we do it.” (DVD). Eschborn, Deutsche Gesellschaft für Technische
       Zusammenarbeit (GTZ) GmbH.
In Lesotho, Making Community Councils
the Gateways to Fighting AIDS

The context                                                                   The state of the AIDS epidemic
                                                                              Based on the results of the Lesotho Demographic
Socio-economic conditions                                                     and Health Survey 2004 and of the Ministry’s
Known as Africa’s “Mountain Kingdom,” the King-                               sentinel surveillance at antenatal clinics in urban
dom of Lesotho is surrounded by South Africa.                                 areas, the prevalence rate among adults 15-49 was
Its lowlands, foothills, mountains, and valleys are                           23.2% at the end of 2005 and had stabilized at a
home to an estimated 1.8 million people. Most live                            very high level.16 The prevalence rate was higher
in rural areas, often accessible only by foot, mule                           in urban areas (29.1%) than in rural areas (21.9%)
or all-terrain vehicle. In 2002, after several years of                       but it was consistently high throughout all 10
civil unrest, Lesotho underwent constitutional                                Districts of Lesotho.Among adults under 40 years
reforms followed by peaceful multiparty parlia-                               old, the prevalence rate was higher among women
mentary elections.                                                            than men.Among 15-19 year olds, 2.3% of men but
                                                                              7.9% of women were HIV-positive; among 20-24
                                                                              years olds, 12.2% of men but 24.2% of women
                                                                              were HIV-positive. Prevalence peaked at 43.9%
                                                                              among women 35-39 years old.
                                                                                   The 2004 survey found that only 12% of the
                                                                              population knew their HIV status and that know-
                                                                              ledge of their status varied from 4.7% among
                                                                              women with no education to 95.1% among men
                                                                              with at least some secondary education. By the
                                                                              end of 2005, there were 22 sites providing antire-
                                                                              troviral therapy to around 8,400 people.This
                                                                              meant that around 14% of the estimated 58,000
                                                                              people in urgent need of antiretroviral therapy
                                                                              were receiving it.17
     Lesotho’s economy is based mainly on subsis-
tence agriculture, especially livestock, though it                            The national AIDS response
exports grains. Its official unemployment level                               In December 2002, Prime Minister Pakalitha Mosili
hovers at around 40% and many of its men work                                 challenged resident representatives of UN-system
in mines in South Africa. The Human Development                               organizations to provide Lesotho’s newly elected
Report 2005 ranks Lesotho at number 149 on the                                Government with good advice on how it should
list of 177 countries covered.The United Nations                              scale up the country’s response to AIDS. Lesotho’s
Population Division estimates that, without AIDS,                             Expanded Theme Group on HIV/AIDS engaged in
the average life expectancy would be 63.9 years                               a process of dialogue, debate and consultation
but, with AIDS, it is only 32.9 years and the popu-                           that, within a few months, resulted in the publica-
lation is declining.15                                                        tion of a policy document entitled Turning a Crisis
                                                                              into an Opportunity: Strategies for Scaling Up
                                                                              the National Response to the HIV/AIDS Pandemic
                                                                              in Lesotho.18 In October 2003, the Cabinet of
                                                                              Ministers adopted this as an official working docu-
                                                                              ment guiding the national response to AIDS and
                                                                              also adopted its recommendations:1) to establish a
                                                                              National AIDS Commission; 2) to make the existing

15 United Nations (2005). World Population Prospects: The 2004 Revision. New York, United Nations Department of Economic and Social Affairs,             9
   Population Division.
16 UNAIDS (2006). 2006 Report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS.
17 WHO (2006). Progress Report on Global Access to HIV Antiretroviral Therapy: A Report on "3 by 5” and Beyond. Geneva, World Health Organization.
18 Kimaryo, S et al, Editors (2004). Turning a Crisis into an Opportunity: Strategies for Scaling Up the National Response to the HIV/AIDS Pandemic in
   Lesotho. A Publication of the Partnership of the Government of Lesotho and the Expanded Theme Group on HIV/AIDS, Lesotho. New Rochelle, New
   York, Third Press Publishers.
     Lesotho AIDS Programme Coordinating Authority           system through the loss of skilled and experienced
     (LAPCA) the Commission’s Secretariat; 3) to “core       employees. This compromises the government’s
     stream” the fight against the epidemic in all sec-      ability to provide services at the same time as it
     tors and levels of government “as a matter of           increases demand for services to curb the epide-
     urgency.”                                               mic and mitigate its impacts.
          In August 2005, Parliament passed legislation           In that context, GTZ began supporting AIDS-
     establishing the National AIDS Commission and           related initiatives when it participated in develo-
     the Government launched a review of the national        ping the document Turning a Crisis into an
     response leading to development of a National           Opportunity.When the Cabinet of Ministers adop-
     AIDS Policy, a Strategic Framework 2006-2010 and        ted the recommendation to “core stream”AIDS, the
     a unified monitoring and evaluation system for          Expanded Theme Group agreed that GTZ’s contri-
     HIV and AIDS programmes. Meanwhile, the AIDS            bution should focus mainly on implementation of
     epidemic affects every aspect of life in Lesotho. Its   that recommendation, still within the context of
     social, economic and institutional consequences         its main focus on “Decentralized Rural Develop-
     will be increasingly serious if the tide cannot be      ment.” In December 2003, GTZ outlined a new
     turned soon.                                            plan for its Lesotho programme, with the follo-
                                                             wing mainstreaming elements:
     GTZ support to Lesotho’s AIDS
     response                                                • Support for the Ministry of Local Government’s
     Under the Lesotho-German bilateral agreement for          programme to empower Lesotho’s Interim
     development cooperation, GTZ and other German             Community Councils to respond to AIDS as they
     development agencies focus on “Decentralized              evolve into permanent Community Councils –
     Rural Development.” Successful decentralization,          known as the “Gateway Approach.”
     however, depends on the presence of competent
     administrative personnel and active civil society       • Continuing support for the Ministry of Public
     representatives at the district and local level. The      Services’ programme to mainstream AIDS
     AIDS epidemic has an enormous and disastrous              through the development and implementation
     impact on Lesotho’s political and administrative          of workplace programmes in all sectors and
                                                               levels of government and by training public
                                                               servants to become HIV and AIDS competent .

                                                             • Continuing support for mainstreaming AIDS into
                                                               the Capacity Building for Land Management –
                                                               for example, by ensuring that the new Land Bill
                                                               will address AIDS-related issues such as the pro-
                                                               perty rights of widows and orphans.

                                                                  In the following, the focus will be on the first
                                                             of these three elements, the Gateway Approach to
                                                             getting local responses to AIDS off the ground.

The Gateway Approach to empowering                                                   Since 2003, GTZ has worked in close coope-
Community Councils                                                              ration with the Ministry of Local Government on
                                                                                continuously developing the ‘Gateway Approach’
Defining the vision, goals and objectives                                       to mainstreaming AIDS into local government.The
Lesotho has ten Districts, each with its own District                           Gateway Approach has the following elements.
Council. In 2002, Lesotho’s Ministry of Local
Government began implementing a decision to
divide each District into Community Council areas                                  Vision. Community Councils are the Gateways
and subsequently each area into Electoral Divisions.                               to Lesotho’s holistic fight against the AIDS epi-
There are typically from 10 to 15 Electoral Divisions                              demic.They coordinate the development of
and one representative from each is voted into                                     Community Council Action Plans in which
the Community Council. A House of Chiefs in                                        HIV and AIDS and their impacts are addressed
each area votes two chiefs onto the Community                                      across all sectors, based on the priorities and
                                                                                   needs of their areas.They also coordinate
                                                                                   and monitor implementation of the plans by
                                                                                   governmental and non-governmental service

                                                                                   Goal. A platform on which the resources and
                                                                                   activities of all stakeholders, from Global Fund
                                                                                   to social responsibility programmes of busi-
                                                                                   nesses, are brought together and coordinated
                                                                                   to address the needs of the population. On
                                                                                   this platform the stakeholders develop and
                                                                                   implement strategies for fighting the AIDS epi-
                                                                                   demic within their respective mandates by
                                                                                   involving communities and their representati-
                                                                                   ves from the outset.A demand based approach
                                                                                   with mainstreaming throughout promotes and
                                                                                   supports community-based initiatives and in-
Council. Each Community Council sends two                                          novations, introduces and affirms the principle
representatives to sit on the District Council.                                    of subsidiarity,19 encourages self help, and aims
There are 128 Community Councils and one City                                      for sustainability of the approaches chosen.
Council– for Maseru, the national capital.The
Community, City and District Councils and their
staff carry some of the responsibilities previously
carried by central government. Prior to the first
local government elections in April 2004, Interim
Community Councils had been appointed and
given limited responsibilities.

19 Subsidiarity is the principle that, when appropriate, central governments give local governments control over matters that of primarily local concern.   11
     Objectives:                                             3. To promote a demand-driven system at local,
     1. To make councillors, council staff and other local   district and national levels
     leaders HIV and AIDS competent                          In a demand-driven system, the priorities of com-
     HIV and AIDS competence requires that each of           munity members in need of services are enshrined
     them knows what HIV is and how it is transmit-          in action plans that inform and guide all local,
     ted; how infection can be prevented; how infec-         district and national authorities and service pro-
     tion can be managed through testing, treatment          viders as they plan and deliver services – all
     and care; that being infected is not an automatic       within the framework of national AIDS policies
     death sentence; how HIV-positive people can live        and strategies.
     long and productive lives.
                                                             The pilot project in the District of Qacha’s Nek
                                                             In late 2003, GTZ and the Ministry of Local
                                                             Government launched a pilot project to begin
                                                             establishing the Gateway Approach in the moun-
                                                             tainous District of Qacha’s Nek.The District had
                                                             21 Interim Community Councils at the time, some
                                                             serving several tiny and remote villages and rural
                                                             settlements where people in need of medical tre-
                                                             atment were accustomed to walking for two or
                                                             three days to the nearest clinic.The aim was to
                                                             build Councils’ capacity to address the AIDS epide-
                                                             mic and use the lessons learned from that expe-
                                                             rience to develop guidelines for the capacity buil-
                                                             ding of Councils throughout Lesotho.
     2. To empower local governments (District and
     Community Councils) to be the Gateways in the           There were two stages to the pilot project:
     fight against HIV and AIDS
     Local governments perform a coordinating role in        • First, training workshops providing councillors
     the development of action plans based on commu-           and other community leaders with basic know-
     nity priorities and monitor their implementation          ledge and skills in fighting HIV and AIDS
     through the support of service providers. Ques-
     tions that can help local stakeholders understand       • Second, evaluation of the impacts – that is,
     what roles they can play in the fight against HIV         assessment of the extent to which Councils
     and AIDS include: what aspects of their work may          were applying the lessons learned in the work-
     facilitate the spread of HIV, what aspects may in-        shops.
     hibit the spread of HIV, what aspects contribute to
     the impact of HIV, what aspects may mitigate the

                                                                                      Each workshop lasted for seven full days, with
                                                                                 facilitators sleeping on floors in village schools
                                                                                 and local women supplying them with food.21 The
                                                                                 workshops asked participants to:

                                                                                 • Reflect on the causes and consequences of HIV
                                                                                   and AIDS, including impacts on people in their
                                                                                   villages, and reflect on effective responses, in-
                                                                                   cluding prevention, treatment, care and support
                                                                                   (including creation of a supportive environment
                                                                                   where people feel safe and comfortable when,
                                                                                   for example, they seek voluntary counselling
                                                                                   and testing)
     For the first stage, the Karolelano ea Tsebo
Facilitators’Association (KaTseFA), a non-govern-                                • Reflect on existing services in their communities
mental organisation based in Lesotho, collaborated                                 and other opportunities for mitigating the im-
with GTZ and the Ministry of Local Government                                      pacts, with particular consideration given to
on planning and conducting the workshops. Each                                     issues of land allocation and natural resource
of the 21 Interim Community Councils was asked                                     management so as to ensure the secure supplies
to invite 50 people – councillors, chiefs and village                              of nutritious food needed to keep both HIV-posi-
headmen, traditional healers, women, herd-boys,                                    tive and HIV-negative people healthy, resistant
and representatives of civil society organizations                                 to infection and able to reap the full benefits of
including faith-based ones – to participate.Two                                    any treatment they may be receiving.
Bosotho facilitators,20 supported by a technical
advisor from the German Development Service                                      • Consider structures and procedures (including
(DED), conducted the workshop for each Council.                                    traditional ones) through which people in their
Each workshop consisted of presentations and                                       communities might assess needs for services,
exercises leading participants to:                                                 plan to meet those needs, marshal the resources
                                                                                   for implementation, and then monitor the resul-
• Acknowledge the existence and understand the                                     ting services.
  basics of HIV and AIDS
                                                                                 • Establish, from among the most knowledgeable
• Appreciate that there is no reason to fear people                                and committed people present, HIV and AIDS
  living with HIV                                                                  Impact Mitigation Committees to advise the
                                                                                   Community Council.
• Become proactive in changing their own circum-
  stances and those of their families and communi-                               • Proceed toward development of a Community
  ties for the better.                                                             Council Action Plan for the Community Council
                                                                                   with HIV and AIDS mainstreamed across each
                                                                                   and every priority project.

                                                                                 • Proceed toward development of a result-orien-
                                                                                   ted monitoring and evaluation system for the
                                                                                   Community Council.

20 In Lesotho, the nationality is Mosotho (singular) or Basotho (plural). The facilitators were Basotho proficient in the main language, Sesotho.   13
21 Subsequently, training has evolved into two separate workshops. Each lasts for five days and the second one focuses on planning.
     Results of the pilot project                                                    The conclusion was not that the pilot project
     From September to December 2004, interviews                                had failed. On the contrary, it had succeeded in
     with 390 of the 650 trained Community Council                              demonstrating that attitudes about HIV and AIDS
     members found that roughly half of the objectives                          could be changed and in identifying the challen-
     had been achieved. Specifically:                                           ges that had to be met through the next stages of
                                                                                getting the Gateway Approach well established.
     • Community Councils had established HIV and
       AIDS Impact Mitigation Committees, an indication                         Developing guidelines for “Quick and Smart”
       of leadership and commitment by councillors                              planning
       and many others.                                                         The pilot project demonstrated the need for a
                                                                                planning methodology that is easy to understand,
     • Councillors were now HIV and AIDS competent                              practical and achieves results within a short time
       and prepared to fight the AIDS epidemic within                           frame.The Community Councillors elected on 30
       the limits of Community Councils’ legislated                             April 2004 have four-year terms and they need to
       powers.                                                                  develop Community Council Action Plans as
                                                                                quickly as possible in order to take full advantage
     • Leaders and the population within each Commu-                            of opportunities to get financial support for pro-
       nity Council area were more unified and prepared                         jects and programmes that benefit the people
       to work together. However, they were unclear as                          living in their areas.
       to who was responsible for doing what and so                                  In early 2005, GTZ began providing financial
       not taking action. In addition, some chiefs (the                         and technical support to planning by the Ministry
       traditional leaders) resisted believing in the exis-                     of Local Government, the Qacha’s Nek District
       tence of HIV and AIDS and saw the new Com-                               Council and the Qacha’s Nek District Planning
       munity Councils as competition that threatened                           Unit. Initially, they worked with just one Commu-
       their traditional authority.They were actively                           nity Council, developing and testing the “Quick
       blocking community mobilization against AIDS                             and Smart” planning methodology. As a result of
       by, for example, saying no one was to talk to                            this work, the Ministry of Local Government and
       children and youth in their areas about such                             GTZ published the Guidebook for Quick and
       “dirty” things.                                                          Smart22 in October 2005. It outlines a two-month
                                                                                planning process that includes:
     • There were few signs of progress toward develop-
       ment of action plans for each village and Commu-                         1. A one-day orientation workshop for District staff
       nity Council.The obstacles were lack of clarity
       as to who was responsible for spearheading                               2. A two-day pre-planning workshop with repre-
       planning processes, lack of knowledge about                                 sentatives and key staff from Community and
       how to go about planning and lack of resources                              District Councils (including District Planning
       to do it.                                                                   Units) and from selected non-governmental
     • There was no progress toward establishing
       monitoring and evaluation systems which, in any                          3. A two-day “area-wise” training workshop for
       case, would normally be provided for in plans                               from two to four Area Planning Support Teams
       and established during the course of implement-
       ing those plans.

     22 Ministry of Local Government and GTZ (2005). Guidebook for Quick and Smart: Community Council Planning Approach. Maseru, Ministry of Local
        Government and Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH.
                                                              Each District has a District Development
4. A two-day workshop for each Community                Coordinating Committee responsible for drawing
   Council, where they are informed about the           up the District Development Plan. Members inclu-
   planning process, asked to begin the process of      de representatives from line ministries of the
   filling out Community Fact Sheets, trained in the    national government, from District Council staff
   use of the Lipitso Information Collection Kit,       and from selected non-governmental organiza-
   and agreed to subsequent steps and schedules,        tions. It is crucial for these committee members to
   including sending letters about the Lipitso to the   be HIV and AIDS competent and have a thorough
   Chiefs (Lipitso are traditional village meetings.)   understanding of mainstreaming and the Quick
                                                        and Smart planning approach. Curriculum has been
5. A month for Community Councillors to have            developed for training District Development Co-
   two-day Lipitso in each of the Council’s             ordinating Committees and it was piloted in the
   Electoral Divisions                                  Mohale’s Hoek District in June 2006.
                                                              The aim is to link community priorities with
6. A five-day workshop for each Community               available financial resources.This makes the pre-
   Council using the information from its               paration of plans urgent, since the national budget
   Community Fact Sheet and from its Lipitso to         for the next fiscal year will be prepared in
   produce a Community Council Action Plan,             November 2006.At the district level, links must
   ending with approval by the Community                be made with available funding from Ministry of
   Council                                              Local Government’s budget, from other ministries’
                                                        budgets, from the Global Fund to Fight AIDS,
7. Submission of Community Council Action Plans         Tuberculosis and Malaria, and from other multilate-
   to the District Council.                             ral and bilateral sources.
                                                              As of July 2006, Lesotho’s National AIDS
                                                        Commission and its partners are close to finalizing
      The Guidebook for quick and smart planning        a new National AIDS Policy and Strategic Frame-
  is contained in the toolbox section of the            work 2006-2010 and both of these documents call
  CD-Rom and provides detailed instructions
                                                        for a comprehensive multisectoral approach to
  for all of the above steps.
                                                        “four domains”: 1) prevention, 2) care, treatment
                                                        and support, 3) impact mitigation and 4) a suppor-
2006 and beyond                                         tive environment where systemic development
All District and Community Councils in Lesotho’s        issues (rural development, poverty, gender equali-
four southern Districts are now HIV and AIDS            ty, etc) are being addressed.The documents recog-
competent. In addition, there are Community             nize the important role District and Community
Councils in all ten Districts with some experience      Councils have to play in accelerating implementa-
with Quick and Smart planning.The lessons learned       tion so that universal access to services can be
in the Qacha’s Nek District were used to refine         achieved as quickly as possible.The Government
the approach taken in Mohale’s Hoek District and        of Lesotho is factoring in the costs of rolling out
the process of refinement has continued and will        the Gateway Approach as it prepares the new
continue into the future.                               national budget.

     In Tanzania, District and Ward
     Empowerment through Capacity Building

     The context                                                                      Knowledge of how HIV transmission can be
                                                                                 prevented was comparatively high, with 87% of
     Socio-economic conditions                                                   adults identifying abstention and 68.9% of men
     The United Republic of Tanzania has a population                            and 62.3% of women identifying both faithfulness
     of more than 38 million people. Most live on the                            to one partner and the regular use of condoms.
     mainland but half a million live on the islands of                          However, risk-taking behaviour was high, too, with
     semi-autonomous Zanzibar. On the mainland, Muslims                          23% of women and 46% of men reporting sexual
     outnumber Christians by a small margin and there                            encounters with a non-marital, non-cohabiting
     are also many adherents to indigenous belief systems,                       partner within the past 12 months.There are many
     while some 99% of Zanzibar’s population is                                  indications that women, in particular – especially
     Muslim.                                                                     if they are poor, have little education and/or live in
           More than 80% of Tanzanians live in rural areas                       rural areas – are at high risk of infection and in
     and most depend on subsistence agriculture for                              urgent need of information and education about
     their livelihoods. Many also participate in commer-                         all matters related to HIV and AIDS.
     cial agriculture, and agricultural products account                              By the end of 2005, around 7% of the estima-
     for around 45% of GDP and 85% of exports.                                   ted 315,000 Tanzanians in urgent need of antiretro-
     Services account for almost 40% of GDP, though                              viral therapy were receiving it.As in most other
     they employ far fewer people. Mining for gold and                           sub-Saharan African countries, this was far short
     other minerals accounts for much of the remai-                              of the “3 by 5” target.26 There were 98 sites (96 on
     ning GDP.The Human Development Report 2005                                  the mainland, 2 on Zanzibar) providing therapy
     ranks Tanzania at number 164 on the list of 177                             and the Government of Tanzania was scaling up its
     countries covered.The United Nations Population                             efforts to make therapy more widely available by
     Division estimates that, without AIDS, the average                          increasing the number of sites, particularly in rural
     life expectancy would be 58 years but, with AIDS,                           areas.
     it is only 46 years.23
                                                                                 The national AIDS response
     The state of the AIDS epidemic                                              In 1985, the Government of Tanzania established
     According to the latest UNAIDS estimates, the                               the National AIDS Control Programme in the
     prevalence rate among adults 15-49 was 6.5% at                              Ministry of Health and adopted the first of a series
     the end of 2005. There were 1.4 million people                              of short- and medium-term AIDS plans that focu-
     living with HIV and, of those, 1.3 million were                             sed mainly on the health sector. In 2000, the
     adults and 710,000 (54.6% of the adults) were                               President declared the AIDS epidemic “a national
     women.24 The 2003-04 Tanzania HIV/AIDS                                      disaster.” In 2001,Acts of Parliament approved a
     Indicator Survey found that HIV prevalence                                  National Policy on HIV/AIDS, established the
     among adults 15-49 varied among the mainland’s                              Tanzania Commission for AIDS (TACAIDS) and
     21 regions from a low of 2.0% to a high of 13.5%                            called for all Districts and Wards to establish multi-
     and averaged 10.9% in urban areas and 5.3% in                               sectoral AIDS committees.TACAIDS worked with
     rural areas. In most regions the prevalence rate                            a broad range of stakeholders to develop mainland
     was higher among women, averaging 12.0% in                                  Tanzania’s Multisectoral Strategic Framework on
     urban areas and 5.8% in rural areas.25                                      HIV/AIDS 2003-2007. It sets nine goals for four
                                                                                 strategic areas: 1) cross-cutting issues, including
                                                                                 provision of an enabling environment; 2) preven-
                                                                                 tion, including a focus on gender issues; 3) care,
                                                                                 treatment and support; 4) mitigation of the socio-
                                                                                 economic impacts of AIDS.

16   23 United Nations (2005). World Population Prospects: The 2004 Revision. New York, United Nations Department of Economic and Social Affairs,
        Population Division.
     24 UNAIDS (2006). 2006 Report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS.
     25 National AIDS Commission Tanzania (2005).2003-04 Tanzania HIV/AIDS indicator survey 2003–2004. March. Dar es Salaam and Calverton, Tanzania
        Commission for AIDS, National Bureau of Statistics, ORC Macro.
     26 WHO (2006). Progress Report on Global Access to HIV Antiretroviral Therapy: A Report on "3 by 5” and Beyond. Geneva, World Health Organization.
     Since 2001, the funding of the AIDS response
from domestic sources (public spending and out-
of-pocket spending by affected people) has more
than doubled and, together with substantial increases
in funding from international sources, this has ena-
bled significant progress. Successful information
and education campaigns have increased the
demands for condoms,Voluntary Counselling and
Testing (VCT) and antiretroviral therapy far                 The Act specifies that each CMAC will have
beyond the country’s current capacity to meet           the Council’s Deputy Chairperson as its Chair-
those demands.The main challenge, now, is to            person, the Council’s Director (chief administrati-
accelerate access to services as quickly as possible    ve officer) as its Secretary and additional commit-
in the rural districts, wards and villages where most   tee members, as follows: Members of Parliament
of Tanzania’s population lives.Tanzania is meeting      from each of the District’s electoral divisions;
this challenge by building the capacities of District   Councillors from each of the District’s Wards; the
and Ward multisectoral AIDS committees.With             District’s AIDS coordinator; representatives of people
funding from the World Bank, it is establishing         living with HIV (one man, one woman), youth
Regional Facilitating Agencies that provide local       (one boy, one girl), faith-based organizations (one
government and civil society organizations with         Muslim, one Christian), the network of NGOs
technical support and also facilitate the distribu-     involved in HIV and AIDS interventions (one), and
tion of funding to service providers.                   other sectors (one). Subsequent to the Act, it was
                                                        decided CMACs should add members representing
                                                        the health, education, community development,
Training Council and Ward                               and agricultural sectors.
Multisectoral AIDS Committees                                CMACs are the key mechanisms for planning
                                                        and coordinating community-based responses to
What are CMACs and WMACs?                               AIDS and they:
Mainland Tanzania, for which TACAIDS is responsi-
ble, is divided into 21 administrative regions and      • Support Wards and villages in establishing and
they are divided into 123 Districts,Towns, Munici-        running their own AIDS committees
palities and Cities. Each has a Council and is divi-
ded into several Wards, which in turn have up to        • Increase community awareness of HIV and AIDS
eight villages. The 2001 Act of Parliament that
established TACAIDS also called for all Councils to     • Assess the HIV and AIDS situation within their
establish Council Multisectoral AIDS Committees           jurisdictions (numbers of people with HIV
(CMACs) and for Wards to establish Ward Multi-            broken down by characteristics, factors
sectoral AIDS Committees (WMACs).                         contributing to new HIV infection and so on)

                                                        • Advise Councils and other authorities at higher
                                                          and lower levels on appropriate by-laws,
                                                          policies, programmes and projects

                                                        • Assess the interests of capabilities of partners
                                                          and potential partners in the response to AIDS.

         Building the capacity of CMACs, through trai-                               A sample of eight District Councils was selec-
     ning and support of their members and other                                ted for participation in the survey using such
     means, is essential if they are to carry through on                        criteria as high prevalence of HIV, large numbers
     the tremendous responsibility assigned to them                             of refugees, large areas without services, and lack
     by the Government of Tanzania.With that in mind,                           of donor support. For each District Council, nine
     in February 2003, the President’s Office, Regional                         of the 19 appointed or potential members of their
     Administration/Local Governments division (PO-                             CMACs were interviewed, five in a group session
     RALG), and TACAIDS sent a circular to all Councils                         and four individually. The survey was conducted
     giving them basic information and asking them to                           by four interviewers, supported by two supervisors,
     take immediate action to establish CMACs by                                from 22 April to 16 May 2003. It found that:
     appointing members and calling meetings.
                                                                                • Five out eight District Councils had not appoin-
     The baseline survey                                                          ted members to their CMACs but were able to
     As a step toward developing a training programme                             identify potential members for the interviews.
     for CMACs,TACAIDS established a Quality Assurance                            Only one District Council could show that the
     team that collaborated with GTZ and evaplan/                                 CMAC had ever had a meeting.A majority of
     University of Heidelberg (a consulting firm) and                             appointed or potential CMAC members did not
     HealthScope Tanzania (another consulting firm) on                            know what their roles and responsibilities were.
                                                                                  Many did not know about TACAIDS and its role
                                                                                  in responding to the AIDS epidemic. Most did
                                                                                  not refer to the circular or any other documents
                                                                                  that had been sent to inform and guide their
                                                                                  participation in the CMACs. Some said that they
                                                                                  did not see the point of CMACs.

                                                                                • Most appointed or potential CMAC members
                                                                                  had little knowledge about HIV and AIDS and
                                                                                  related issues, such as the factors that put adults
                                                                                  and youth at risk of infection, socio-cultural atti-
                                                                                  tudes and practices that may contribute to risk,
                                                                                  and stigma and discrimination.

                                                                                • Most were unable to describe practical approa-
     designing and carrying out a survey to establish                             ches to such tasks as planning a youth aware-
     baseline information against which to measure the                            ness campaign and running a training workshop.
     results of training. The survey instrument was a                             Most were able to identify resources, other than
     “Pre- and post for CMACs,” with questions to deter-                          money, available in their communities but few
     mine CMAC members’ levels of knowledge about                                 knew how to begin developing a budget that
     TACAIDS, HIV and AIDS, needs for and barriers to                             would help them gain access to financial resour-
     AIDS advocacy, and other areas to be covered in                              ces within or outside their communities. Most
     the trainings (see below) to ensure their AIDS                               could not see the importance of monitoring and
     competence.27 This same instrument could be                                  evaluation, though some had been involved in
     used after training, to find out what members had                            AIDS-related projects and programmes. Few
     learned and what their needs for additional train-                           could name basic elements of a good project or
     ing might be.                                                                programme proposal.

18   27 TACAIDS, evaplan/UH (2003). Pre-test and Post for CMACs. Dar es Salaam, Tanzania Commission for AIDS, evaplan/University of Heidelberg.
• None of the District Councils had arranged for                                    The result, contained in the toolbox section
  initial orientation or training workshops for their                          of the CD-Rom, was four training manuals, with
  CMACs. Failures to circulate or read information                             10 training modules plus a field guide, as follows:
  (partly due to low levels of competence in the                               Book 1 1.Advocacy
  relevant language), lack of budgets for meetings                                      2. Basic Facts, Prevention and Control
  and failures to assign a staff person with respon-                                       of HIV/AIDS
  sibility for making things happen were among                                          3. Sociocultural Factors and Concepts
  the reasons for lack of action on CMAC appoint-                              Book 2 4.Team Building, Leadership and
  ments, meetings and workshops.28                                                        Partnership
                                                                                        5. Resource Management
     On this basis, the survey identified: 1) the                                       6. Participatory HIV/AIDS Planning
need for research into socio-cultural attitudes and                                     7. Participatory Monitoring and
practices of major ethnic groups as they relate to                                         Evaluation
HIV and AIDS, 2) the need for District multisecto-                             Book 3 8. Proposal Writing and Assessment
ral AIDS strategies, developed through consulta-                                        9. Report Writing Skills
tions with a broad range of stakeholders, 4) the                                        10. Communication and Facilitation
need to build the capacity of Regional Administra-                             Book 4 Field training guide.30
tive Secretariats to support, monitor and evaluate
council AIDS activities within each of mainland
Tanzania’s 21 administrative regions, 5) the need
for further CMAC capacity building.

Developing training material
The baseline survey also constituted an assessment
of learning needs for the development of training
course material.Through a series of workshops, a
group of educators and other professionals – re-
presenting organisations involved in developing
and implementing in Tanzania’s response to AIDS
– outlined the course concept, drafted the curricu-
lum and developed training modules.The process
was exceptionally participatory and is described
in full on a CD ROM.29 The modules were tested in
two Districts and then refined.

28 TACAIDS (2003). Baseline Assessment Study Results: Quality Assurance of CMACs Training. Dar es Salaam, Tanzania Commission for AIDS,                   19
   Healthscope Tanzania, Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH – BACKUP Initiative, evaplan/University of Heidelberg.
29 Participants were from PO-RALG, TACAIDS, Mzumbe University, evaplan/University of Heidelberg, Iringa Primary Health Care Institute, African
   Medical Research Foundation, CARE, UNAIDS, TANESA (Tanzania Netherlands Project to Support AIDS control in the Mwanza Region), and GTZ. A
   description of the process is available on CD ROM on the evaplan/University of Heidelberg website at [please provide direct link to the actual item,
   not just to the website.
30 TACAIDS, GTZ BACKUP, evaplan/UH (2004). Training Manuals for HIV/AIDS Committees at Local Government Authorities. Dar es Salaam, Tanzania
   Commission for AIDS, Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH – BACKUP Initiative, evaplan/University of Heidelberg.
     Facilitating and evaluating training workshops             In June 2004, the training facilitators, represen-
     In December 2003,TACAIDS recruited 50 training        tatives from TACAIDS and the development part-
     facilitators who were given a four-day course on      ners participated in a two-day workshop to draw
     how to use the modules in training workshops.         lessons from the experience of training CMACs.
     The agreed approach was to cascade down               The main lessons were:
     through a series of workshops that began with
     Regional Administrative Secretariats, moved on to     • Because they had been refined through pre-
     CMACs and would eventually cover WMACs and,             testing in two Districts, the 10 training modules
     possibly, village AIDS committees. In early 2004, a     had proved to be user-friendly and relevant.
     three-day training workshop was held for the
     Regional Administrative Secretariats and focused      • Workshops are more successful when there are
     on modules that would help the support, coordi-         several facilitators with diverse skills, beliefs,
     nate and monitor the work of CMACs. From March          ages, and experiences, increasing the likelihood
     through late May 2004, 14-day training workshops        that they will be able to communicate with par-
     were held for each of the CMACs.                        ticipants of varying background, belief, language,
                                                             and literacy.

                                                           • The circulation of written policies and guideli-
                                                             nes has to be followed up with more personal
                                                             communications or else people are likely to
                                                             ignore or misinterpret them.

                                                           • CMACs are weakened when people appointed
                                                             as members are not genuinely committed to the
                                                             AIDS response and when members are appoin-
                                                             ted for one-year terms and then replaced by new
                                                             members with no training or experience. (Though
                                                             they were members of CMACs, few Members of
                                                             Parliament attended the training sessions.)

                                                           • Stigma and discrimination and discomfort with
                                                             open discussion of HIV and AIDS and related
                                                             activities are still prevalent, even among members
                                                             of CMACs, with some indicating that they would
                                                             prefer not to have people living with HIV on
                                                             their committees.

Planning the next steps
In July 2004,TACAIDS, evaplan/University of
Heidelberg and the GTZ Health Programme in
Tanzania held a one-day workshop with all the
stakeholders involved in this initiative.31 After
breaking into three working groups, they came
together and agreed on a plan of action for the
next 6 to 12 months. Elements included:
                                                                            • The role of TACAIDS 1) build the capacity of
• Technical assistance to CMACS 1) select 10 of                              Regional Administrative Secretariats to support
  the training facilitators used for the workshops                           CMACs, 2) possibility have Regional Administra-
  and give them additional training as providers of                          tive Secretariats appoint focal persons on AIDS,
  technical support to CMACs while they develop                              such as the Regional Community Development
  strategic plans, programmes to counter stigma                              Officers, 3) strengthen linkages between PO-RALG
  and discrimination and so on, 2) develop a                                 and TACAIDS, 4) strengthen linkages between
  checklist to support CMACs, helping them keep                              District AIDS Coordinators and District Planning
  track of their actions and procedures – reports                            Officers and Directors, through joint training,
  to Council, frequency of meetings, actions to                              5) raise District Council and public awareness
  develop profiles of the district’s AIDS epidemic,                          of TACAIDS and its work.
  etc, 3) develop tools and indicators for monito-
  ring CMACs, 4) collaborate with Regional                                  • Political will 1) develop tailor-made peer edu-
  Administrative Secretariats on taking further                               cation programmes targeting a variety of leaders
  steps to put monitoring and evaluation in place,                            and getting them to accept their ownership of
  5) facilitate development of 5-year strategic AIDS                          and duty to address HIV and AIDS – for example,
  plans for districts, 6) provide training and support                        Members of Parliament, Regional Commissioners,
  to district AIDS coordinators (most of whom                                 Regional Administrative Secretaries, District
  were the district Community Development                                     Councillors, District Management Teams, 2) as an
  Officers, by this stage).                                                   immediate step, hold joint PO-RALG/TACAIDS
                                                                              orientation workshops for each of those catego-
• Training WMACs 1) with help of the training                                 ries of leader, using the most relevant training
  facilitators, identify 6 members from each CMAC                             modules, 3) organize a forum and establish a
  and train them to facilitate training workshop for                          coalition of organizations engaged in AIDS advo-
  WMACs, 2) focus especially on the modules                                   cacy and leadership development.
  most relevant for WMACs – for example, helping
  them understand the important role they can
  play in monitoring and evaluation, 3) adapt the
  modules to the local context – for example, the
  need to address particular socio-cultural practices.

31 Fulgence, B (2004). Council AIDS Multisectoral Committees’ Capacity Building: Report of the Planning Meeting Held on July 23rd 2004 at Kibaha.   21
   Dar es Salaam, Tanzania Commission for AIDS, Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH, evaplan/University of Heidelberg.
         The workshop participants agreed that provi-                               • To support the next steps in planning the way
     ding technical assistance to CMACs during their                                  forward, and
     next 6 to 12 months was crucial, in order to make
     sure their training was applied and that they conti-                           • To prepare analytic reports to TACAIDS.
     nued to learn through practical experience until
     they became expert at addressing HIV and AIDS in                                   The facilitators’ final report36 summarized the
     their districts, wards and villages. Sustaining the                            findings for each District and City Council and
     CMACs efforts beyond their next 6 to 12 months                                 noted these achievements:
     would require training and supporting Regional
     Administrative Secretariats so they could provide                              • Six of the eight CMACs had had at least three
     continuous support to CMACs.                                                    meetings over the past year, though one had had
                                                                                     no meeting.Average attendance was 77% and all
     The results, assessed one year later                                            seven CMACs that had met also had adopted and
     One year later, in July 2005, the GTZ BACKUP                                    implemented resolutions on such matters as
     Initiative32 and evaplan/University of Heidelberg                               establishing and training WMACs, doing profiles
     collaborated with TACAIDS on providing supporti-                                of the district’s epidemic, promoting AIDS aware-
     ve follow-up to the trained CMACs.The CMACs of                                  ness in schools, developing information/educa-
     the seven District Councils and one City Council                                tion/ communication material, and so on.
     in the Mbeya Region were chosen as pilots.Two
     facilitators were recruited and provided with three                            • The new Regional Facilitating Agency had already
     days of training plus three tools: 1) terms of refe-                             begun providing technical support to six CMACs
     rence,33 2) a questionnaire for assessing the                                    and was scheduled to visit the other two during
     CMACs’ capacities to develop multisectoral AIDS                                  the next month (August 2005). Results included
     plans34 and 3) the template for an analytical report                             the mapping and assessment of AIDS-related ser-
     for submission to TACAIDS.35                                                     vices and facilities provided by civil society
          The facilitators visited each CMAC for three                                organizations and assessment of training needs
     days to:                                                                         of those organizations and local government.

     • Conduct structured interviews with key mem-                                  • Seven CMACs had developed multisectoral AIDS
       bers of each CMAC                                                              plans and four had submitted their plans to
                                                                                      TACAIDS for analysis.
     • Examine the CMAC’s multi-sectoral AIDS plans
                                                                                    • Four of the Districts had facilities providing
     • Identify the CMAC’s needs for technical support                                anti-retroviral therapy; all eight had at least five
                                                                                      civil society organizations providing AIDS-related
     • Facilitate better collaboration among key people                               services; among the services being provided by
                                                                                      them and government facilities were Volunteer
     • Initiate dialogue about meeting the budget                                     Counselling and Testing (VCT), support for
       needs of the CMAC and the WMACs                                                orphans, sensitization on care and treatment of
                                                                                      people living with HIV, home-based care, treat-
     • Deliver training manuals with drafts of a special                              ment of sexually transmitted disease (STI), pre-
       WMAC component and initiate technical sup-                                     vention of mother-to-child transmission (PCMT),
       port for getting WMACs established and trained                                 and public awareness.

     32 The GTZ BACKUP Initiative helps countries take advantage of the opportunities provided by global initiatives to respond to HIV and AIDS, tuberculosis
        and malaria.
     33 TACAIDS, evaplan/UH (2005). Terms of Reference for Facilitators to do the CMACs follow up. Dar es Salaam, Tanzania Commission for AIDS, eva-
22      plan/University of Heidelberg.
     34 TACAIDS, GTZ BACKUP, evaplan/UH (2004). Follow up of CMACs Activities at Council Level, questionnaire for the capacity assessment of CMACs in
        developing multi-sectoral HIV/AIDS plans. Dar es Salaam, Tanzania Commission for AIDS, Deutsche Gesellschaft für Technische Zusammenarbeit
        (GTZ) GmbH – BACKUP Initiative (Building Alliances Creating Knowledge Updating Partners), evaplan/University of Heidelberg.
     35 TACAIDS, evaplan/UH (2005). Analytical Report: Follow up activity of CMACs. Dar es Salaam, Tanzania Commission for AIDS, evaplan/University of
     36 TACAIDS (2005). Report of Supportive Follow Up of CMACs – Mbeya Region. Dar es Salaam, Tanzania Commission for AIDS.
• There were a combined total of 138 Wards in          • Five CMACs had no collaboration with civil
  the eight Districts and all had taken steps to         society organizations (CSOs). In most Districts,
  establish WMACs; the composition of 30 WMACs           CSOs did not collaborate with each other
  was verified and the training of 26 WMACs had          through networks. Most CSOs were not well
  begun.The Wards had all acted on their own to          informed about the National Policy on HIV/AIDS,
  establish WMACs after receiving the guidelines.        the Multisectoral Strategic Framework on HIV/
  In one Ward, all villages had established Village      AIDS 2003-2007 and the support those docu-
  Multisectoral AIDS Committees.                         ments provide for their endeavours.

• Since the CMACs had been established and trai-       • WMACs were in the early stages of development
  ned, they had retained 85% of their members.           and Village Multisectoral AIDS Committees were
  Six, however, had no persons living with HIV           even less developed.
  among their members and such persons were
  recruited during the facilitators’ visits.           • Twenty members of CMACs had never been
                                                         trained and the same was true of two of the
   The final report also noted a number of               Council HIV and AIDS Coordinators (CHACs)
remaining challenges:                                    who were acting, in effect, as Secretary to
                                                         CMACs. CHACs were sometimes not members of
• The agendas for CMAC meetings often included           the District Council’s Management Team and so
  items that were not strictly related to the CMACs’     not tied into budgetary and planning processes
  duties. Minutes were often not distributed in          and not skilled at budgeting. Shortage of finan-
  time for members to have read them before the          cial resources and equipment were prevalent
  next meeting. 4 CMACs had no meeting calen-
  dars and members were often given short noti-        • Upcoming elections meant there was likely to be
  ce of meetings, meaning they were unable to            significant change-over of Members of Parliament
  attend because they had other commitments.             and District Councillors and therefore of CMAC
  Most CMACs reported that Members of Parlia-            members.The new members would be in need
  ment had never attended their meetings.                of training.

• Most CMACs had not divided up their responsi-             The final report made recommendations
  bilities by assigning specific roles to specific     addressing the above challenges, emphasizing the
  members and many CMAC members remained               need for CMACs and their partners to keep lear-
  unclear as to exactly what their roles were          ning from their experiences and building their
  meant to be.                                         capacities to respond to AIDS as effectively as
• CMACs reported that, while they had developed             For the financial year 2006-2007,Tanzania’s
  multi-sectoral AIDS plans and proposed AIDS          Ministry of Finance has made funding available for
  projects and programmes in a variety of sectors,     Councils to undertake AIDS-related activities,
  only items pertaining to the health sector got       based on their populations and levels of poverty.
  through Councils’ planning and budgeting pro-        This means that, for the first time, CMACs will
  cesses. One result was that the plans of some        have opportunities to put their learning into prac-
  civil society organizations were not incorporated    tice and plan multisectoral activities knowing
  in the Council Development Plan and a knock-on       there will be sufficient money available to support
  effect was that some civil society organizations     those activities.
  were bypassing CMACs and going directly to the
  Council Management Team with their proposals.
     In Mpumalanga, Mainstreaming AIDS in
     Provincial, District and Local Government
     The context                                                                      The survey found that, throughout South Africa,
                                                                                 race is an important factor in HIV prevalence largely
     Socio-economic conditions                                                   because of the socio-economic inequalities between
     One of nine provinces in the Republic of South                              the races. Poor people often live in informal hous-
     Africa, Mpumalanga covers 6.4% of the country’s                             ing settlements, where HIV prevalence is much
     area and is home to 6.9% of its population, or                              higher than elsewhere. Countrywide among adults
     more than 3.2 million people.37 Situated in the                             15-49, HIV prevalence was 13.9% in formal settle-
     north eastern part of the country, it borders on                            ments, whether urban or rural, but 25.8% in infor-
     Mozambique and Swaziland. It suffers from high                              mal urban settlements and 17.3% in informal rural
     rates of unemployment, ranging from 24.8 to                                 settlements.
     30.1% over the 2001 to 2005 period.38 South                                      By the end of 2005, an estimated 235,000 or
     Africa’s 2001 census found that 27.5% of                                    21% of all South Africans in urgent need of antire-
     Mpumalanga’s adults who were more than 20                                   troviral therapy for AIDS were receiving therapy,
     years old had never attended school and another                             through public or private health services.Among
     15.5% had attended but not completed primary                                those receiving it, 93% were still alive after one
     school.39                                                                   year, an indication that treatment and care are of
          According to the South Africa Human                                    high quality when available.41
     Development Report 2003, Mpumalanga had hig-
     her than the country’s average per capita Gross
     Domestic Product, but it also had higher than the
     country’s average income inequality. An estimated
     54.8% of its population lived below the national
     poverty line. Largely due to the AIDS epidemic and
     its average life expectancy had declined from 62.3
     years in 1990 to 46.0 years in 2003.

     The state of the AIDS epidemic
     In 2005, a household survey on HIV and AIDS que-
     stioned and gave HIV tests to far more South
     Africans than any previous survey had done and
     found that HIV prevalence was still increasing but
     at a slower rate than in the past.40 Of the nine pro-
     vinces, Mpumalanga had the highest rate of HIV
     prevalence (23.2%) among adults 15-49.Among
     those less than 35 years old, the prevalence rate
     was much higher among females than among
     males. For example, among 20-24 year olds, 6.0%
     of men but 23.9% of women were HIV-positive;
     among 25-29 year olds, 12.1% of men but 33.3% of
     women were HIV-positive.

     37 Statistics South Africa (2005). Mid-year population estimates, South Africa 2005. Pretoria, Statistics South Africa.
     38 Statistics South Africa (2005). Labour force survey September 2005. Pretoria, Statistics South Africa.
     39 Statistics South Africa (2005). Primary tables Mpumalanga Census ’96 and 2001 compared. Pretoria, Statistics South Africa.
     40 HRSC (2005). South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey. Johannesburg, Nelson Mandela
        Foundation (NMF) and Human Sciences Research Council (HSRC) of South Africa.
     41 WHO (2006). Progress Report on Global Access to HIV Antiretroviral Therapy: A Report on "3 by 5” and Beyond. Geneva, World Health Organization.
The national AIDS response                                                  Mainstreaming in Mpumalanga Rural
The Government of the Republic of South Africa                              Development Programme
recognized the need for a multi-sectoral response                           Launched in 2001, the Mpumalanga Rural Develop-
to AIDS in 1997 and, after extensive consultations,                         ment Programme (MRDP) has three principle part-
produced the National Strategic Framework for                               ners – the Mpumalanga Provincial Government,
HIV and AIDS and STIs 2000-2005. In 2000, Cabinet                           German Technical Cooperation Agency (GTZ) and
established the South African National AIDS Council                         German Development Service (DED) – and a num-
(SANAC) as a mechanism for building greater co-                             ber of implementing partners, including several
operation between government and civil society                              departments and two district municipalities. Its
in implementation of the plan. Since 2004, the                              main aims are to improve service delivery and sup-
federal government has been implementing the                                port economic development and sustainable natu-
Operational Plan for Comprehensive HIV and AIDS                             ral resource development in the province’s rural
Care, Management and Treatment,42 calling for                               “poverty pockets.”Achieving these aims involves
involvement of the nine provinces.43 The Plan calls                         working closely with Local Municipalities and
for significant new investments to reduce the bur-                          their constituent communities.
den on health facilities and staff, first, through pre-                          The decision to have an HIV and AIDS compo-
vention and, second, through keeping HIV-positive                           nent as part of the MRDP followed all partners’
people healthy with good nutrition, healthy lifesty-                        recognition that the AIDS epidemic had serious
les, prevention and treatment of opportunistic in-                          implications for the entire programme.They
fections, and proper management of drug regimes.                            agreed to mainstream responses to HIV and AIDS
     Though the federal government has been                                 in the MRDP, itself, and in the core programmes of
encouraging the nine provinces and their districts                          partner institutions.The MRDP mainstreaming pro-
and municipalities to establish their own AIDS                              cess links the three levels of government (provin-
councils since 2001, the South African National                             cial, district and local) and all departments of
AIDS Council (SANAC) itself has not been a very                             government and also links civil society to govern-
strong and effective vehicle for multisectoral enga-                        ment through AIDS councils and the Home Based
gement and coordination. Many provinces, districts                          Care (HBC) programme.
and municipalities established AIDS councils as                                  At the level of the Mpumalanga Provincial
early as 2001 but many of these councils soon                               Government, the MRDP has provided technical
became inactive. Such was the case with the                                 assistance to:
Mpumalanga AIDS Council and the province’s
District and Local Municipal AIDS Councils. Since                           • Mainstreaming HIV and AIDS mitigation measu-
early 2004, due in part to new impetus given by                               res into the work of all government departments
the federal government’s Operational Plan and in
part to mounting pressure from civil society orga-                          • Implementing an HIV and AIDS workplace
nizations,AIDS councils at all levels have been                               policy for all government employees
reviving throughout South Africa.
     Within the Mpumalanga Provincial Govern-                               • Strengthening the Provincial Government’s
ment, the Department of Health and Social                                     support for Home Based Care (HBC)
Services (DHSS) has principle responsibility for
overseeing the development and implementation                               • Strengthening the Provincial Government’s
of AIDS policies and programmes.While it has                                  support for Voluntary Counselling and Testing
been responding to HIV and AIDS more vigorously                               (VCT).
in the past two years, it still fails to take full advan-
tage of the federal government funding available
for its response.
42 Department of Health (2003). Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa. Pretoria,
   Department of Health, Republic of South Africa.
43 SADC (2003). SADC HIV and AIDS Strategic Framework and Programme of Action 2003-2007. Gaborone, Southern African Development
         At the level of District and Local Municipalities,                      The workshops were built around three questions:
     the MRDP has provided technical assistance to:
                                                                                 1. How the epidemic is likely to affect the depart-
     • Mainstreaming HIV and AIDS                                                   ment’s goals, objectives and programmes?

     • Reviving and strengthening District and Local                             2. How the spread of HIV is caused by or contri-
       AIDS Councils and support development of                                     buted to by the department?
       District and Local strategies on HIV and AIDS.
                                                                                 3.Where does the department have a comparative
     Mainstreaming in provincial                                                   advantage to contribute to limiting the spread of
     government departments                                                        HIV and mitigating the impact of the epidemic?
     Between August 2003 and March 2004, MRDP sup-
     ported a series of “mainstreaming” workshops for                            The introductory workshop
     provincial government departments.44 As they                                An introductory workshop on 4 August 2003 had
     were the experts in their own work, it was impor-                           participants from all departments plus the Office
     tant to give them ownership of the mainstreaming                            of the Premier. It consisted of presentations and
     process at the outset by involving senior and                               exercises encouraging participants to:
     middle managers in planning the workshops befo-
     re participating in them. Given that the structure,                         • Reflect on the causes and consequences of
     operating style and work of each of the depart-                               HIV and AIDS
     ments were unique, content and process of the
     departmental workshops were adapted to the                                  • Consider how their departments were already
     specific demands of the different departments.                                responding to AIDS (e.g., by contributing to eco-
                                                                                   nomic development and so reducing the poverty
                                                                                   that contributes to the spread of HIV) and how
                                                                                   they were already linked to each other through
                                                                                   networks to cooperate on certain matters

                                                                                 • Consider how they might use existing networks
                                                                                   or build new networks for collaboration on the
                                                                                   development and implementation of AIDS strate-
                                                                                   gies that build on the comparative advantages of
                                                                                   each department

                                                                                 • Formulate recommendations for actions their
                                                                                   departments could take, individually and collec-
                                                                                   tively, to contribute to the AIDS response.

26   44 MRDP (2003, 2004). HIV/AIDS Mainstreaming in Mpumalanga/RSA: Implementing a new strategy within the Provincial Government. Series of unpu-
        blished reports on workshops assisted by the Centre for Advanced Learning in Rural Development (SLE), Humboldt University, Berlin. Nelspruit,
        MRDP (GTZ and Mpumalanga Office of the Premier).
Seven departmental workshops                          • Formulate recommendations for action by their
Over the following months, there were seven one-        department.These typically covered formation of
or two-day workshops for each of the following          task teams, accountable to senior management,
departments: 1) Public Works, Roads and Trans-          to drive the mainstreaming process forward;
port; 2) Local Government,Traffic Control and           designation of main personnel responsible at
Traffic Safety; 3) Social Services; 4) Agriculture,     headquarters and elsewhere; ways of linking and
Conservation and Environment; 5) Finance and            collaborating with other partners in provincial,
Economic Affairs; 6) Education; 7) Health. Each         district and local governments and outside of
consisted of presentations and exercises encoura-       government;
ging participants to:
                                                           For each department, a fact sheet was formula-
• Discuss ways their department may be contribu-      ted, highlighting the specific impact of HIV and
  ting to impacts of the epidemic. For example,       AIDS on the deparment’s area of work and ways
  participants from the Department of Public          in which the department might contribute to an
  Works, Roads and Transport noted that lack          effective AIDS response:
  of coordination in public transport schedules
  leaves people stranded overnight in places               The resulting series of 9 fact sheets on
  without safe and adequate sleep-over possibi-         mainstreaming a responds to HIV and AIDS
                                                        can be found in the toolbox section of the
  lities, exposing them to risk of sexual assault
  and HIV infection.

• Discuss ways their department might respond         Mainstreaming in district and local
  to HIV and AIDS internally, in its workplaces,      government
  and externally, in its work. For example, the       The MRDP supports two District Municipalities,
  Department of Public Works, Roads and               Ehlanzeni and Nkangala, and their constituent
  Transport noted that they have opportunities        Local Municipalities as they build their capacity to
  to distribute condoms; provide referrals to AIDS-   respond to AIDS within the context of their deve-
  related services; influence contractors who         lopment programmes.Their aim is to integrate
  may discriminate against HIV-positive people        AIDS strategies into their Integrated Development
  in their own workforce; give priority in their      Plans and to coordinate the AIDS-related activities
  own planning and budgeting to developing            of all stakeholders in their communities – provincial
  and improving infrastructure for AIDS-related       government departments, their own operations
  services.                                           and civil society organizations, including community-
                                                      based ones that provide services.
• Develop proposed operational plans for the
  main units of the department.These plans iden-
  tified activities, indicators for monitoring and
  evaluation, persons responsible, target dates for
  achievement, budgets, and linkages to potential
  partners in other government departments and
  to organizations outside government.They
  also noted institutional constraints (e.g., lack
  of financing) that might have to be taken into
  account before finalizing these plans.

     Nkangala workshop                                                               The workshop for the municipalities used the
     In 2004, Nkangala and its Local Municipalities                              same exercises that had proved useful in the
     resolved to solicit the support of community-                               workshop for provincial government departments,
     based organizations and other stakeholders and                              described earlier, and, like them it concluded with
     revive and strengthen their dormant AIDS councils                           participants developing recommendations for
     and then develop strategies for their responses to                          action.
     AIDS.They asked the MRDP to support these end-
     eavours by assisting them in planning and facilita-                         Nkangala AIDS summit
     ting a mainstreaming workshop.45 Participants in                            In June 2006, with two years of experience apply-
     the workshop identified the following opportuni-                            ing the lessons from the workshop described
     ties to contribute to an effective local AIDS                               above – and soon after the Local Government
     response:                                                                   elections – Nkangala District Municipality held a
                                                                                 summit bringing together political leaders and
     • They are at the front lines of the epidemic,                              staff from South Africa’s Department of Provincial
       where its impacts are felt and where AIDS-rela-                           and Local Government, key departments of the
       ted services are delivered to the people who                              Mpumalanga Provincial Government, the District
       need them.The Integrated Development                                      and its Local Municipalities, and private businesses
       Planning process in each District and Local                               and civil society organizations operating in the
       Municipality gives them opportunities to partici-                         district.The aims of this summit were:
       pate in assessing needs and planning for such
       services.                                                                 • To create awareness around Local Government
                                                                                   responses to HIV and AIDS
     • They are also well-placed to understand and
       counter local traditions and attitudes that contri-                       • To share experiences and lessons and consider
       bute to stigma and discrimination and to deve-                              ways they could harmonize and coordinate their
       lopment programmes to counter those pheno-                                  efforts
       mena; to identify and intervene in situations
       (e.g., eviction from housing) that call for an                            • To review the role and status of the District and
       urgent response; to identify and involve traditio-                          Local AIDS Councils and consider their needs for
       nal healers and popular community leaders in                                broader representation and technical support
       contributing to the AIDS response
                                                                                 • To review South Africa’s national AIDS policies
     • They can assist with the establishment and                                  and strategies and consider how it can be imple-
       support of community-based organizations that                               mented in Nkangala
       establish and operate Home Based Care centres,
       youth-friendly clinics and facilities and services                        • To develop a strategic framework for Nkangala
       supported by national and provincial programmes.                            to respond to HIV and AIDS.

     • They can mainstream HIV and AIDS measures                                      The key outcomes of the summit will be pres-
       into their own workplaces and work.                                       ented to the District Council in the form of resolu-
                                                                                 tions. Once approved by District Council, these
                                                                                 will be binding for the district and its local munici-

28   45 MRDP and Nkangala District Municipality (2004). Nkangala District consultative workshop: Mainstreaming HIV/AIDS mitigation measures, 18 June
        2004. Nelspruit, MRDP (GTZ and Mpumalanga Office of the Premier).
Support for District and Local AIDS Councils           • Political leaders in Local Municipalities are more
Over the past six years, many District and Local         aware of HIV and AIDS and are getting more
Municipalities in Mpumalanga have established            involved in AIDS-related activities. For example,
District and Local AIDS Councils.To get them well-       the Mayor, Speaker and Councillors are getting
established and operational, the MRDP has provi-         actively engaged in reviewing HIV and AIDS stra-
ded a number of them with technical support in:          tegies developed by Local AIDS Councils.

• Developing terms of reference and preparing              Through 2006 and 2007, MRDP’s mainstrea-
  and facilitating induction workshops Applying        ming support to Provincial Governments depart-
  for funding for capacity building and other acti-    ments will focus on implementation of selected
  vities                                               projects of three key departments:Agriculture,
                                                       Local Government and Housing, and Economic
• Assessing impacts of AIDS on their areas, map-       Development and Planning. For example, it will
  ping and assessing existing services and the         support a project to promote food security and
  need for new services, developing strategies and     gardening and, with the German Development
  action plans, and identifying needs for resources    Service (DED), support capacity building of the
  and coordinating structures and processes.           Small Enterprise and Development Agency, inclu-
                                                       ding its capacity to promote and support workpla-
Results and the way forward                            ce programmes to respond to HIV and AIDS.
Most departments in the Mpumalanga Provincial              The MRDP’s continuing support to District
Government have responded to issues raised in          and Local Municipalities will include:
the training workshops by upgrading the positions
of their focal persons on HIV and AIDS (i.e., their    • Supporting AIDS Councils in carrying out their
Gender Focal Persons, whose responsibilities             activities, including developing and reviewing
cover a number of issues) and giving them more           AIDS strategies
staff support and budgets to carry out their duties.
In addition, half of the provincial departments        • Training Municipal Councillors (starting in July
have mainstreamed AIDS strategies into their five-       2006) to mainstream the AIDS response into
year strategic plans – naming AIDS as a key chal-        their Integrated Development Plans
lenge and outlining strategic goals, objectives and
activities to meet the challenge.                      • Supporting capacity building of District and
                                                         Local AIDS Councils they can participate in the
With technical support from MRDP:                        Integrated Develop Planning process and make
                                                         sure that HIV and AIDS programmes and pro-
• Two Local Municipalities have appointed HIV            jects are budgeted
  and AIDS Coordinators.
                                                       • Supporting a workshop for all District and Local
• Six Local AIDS Councils have developed HIV and         AIDS Council members, givig them an opportu-
  AIDS strategies. One of these is approved by the       nity to share experiences and lessons learned
  Local Municipal Council and approval of the
  others is pending.                                   • Mainstreaming the AIDS response into the Local
                                                         Economic Development Strategy of one district.

     Drawing Lessons from Lesotho,
     Tanzania and Mpumalanga
     Achievements, so far                                       The main challenges and some ways
     GTZ’s role is to provide technical assistance and          of meeting them
     thus facilitate the work of its partners in national,      Cooperative development partners everywhere
     district and local government, civil society and           will be familiar with the kinds of challenge GTZ
     private enterprise. Its achievements in supporting         and its partners have been facing in Lesotho,
     HIV and AIDS initiatives in Lesotho,Tanzania and           Tanzania and Mpumalanga.The main ones are:
     Mpumalanga can be measured largely in terms of
     its success at getting them established and launched.      Lack of money The 2006 Report on the global
     Continuing success will depend on carry-through            AIDS epidemic confirms that, globally and within
     by its national, provincial, district, and local govern-   most developing countries, the money available
     ment partners in those countries and on their              for the response to AIDS has increased substantial-
     partners in civil society and the private sector.          ly over the past five years but much of the money
     It will also depend on continuing financial and            never reaches the front lines of the epidemic
     technical support by the international partners,           where AIDS-related services are delivered to the
     including GTZ.                                             people who need those services.There is urgent
          Meanwhile, GTZ’s partners in Lesotho,Tanzania         need to simplify bureaucratic processes, to sup-
     and Mpumalanga have been pioneers in the move              port governments in accessing the money and
     to decentralize and mainstream the AIDS response           managing expenditure, to streamline the flow of
     and give it solid foundations on the front lines of        money to the front lines of the epidemic, and to
     the epidemic, in the communities where service             put it to work in communities.That will require
     providers meet the people who need HIV and AIDS            hard work from both ends, from the international
     prevention, treatment and care and impact mitiga-          level on down and from the local level on up.
     tion.They have been learning by trial and error
     and taking measures to correct errors as they go.          => Getting prepared to put the money to
                                                                   work It is a matter of utmost urgency that
                                                                   community-based stakeholders work together
                                                                   and demonstrate that they are well-prepared to
                                                                   put any available money to work, by comple-
                                                                   ting their needs assessments and action plans
                                                                   and by lining up programmes and projects that
                                                                   need financing.With these at the ready, they
                                                                   can become strong advocates on their own

                                                        High turn-over in personnel Problems com-
                                                        mon to Lesotho,Tanzania and Mpumalanga are
                                                        high turn-over among elected officials, staff and
                                                        volunteers in government at all levels and in civil
                                                        society organizations. In addition, there is often
                                                        political interference so the most qualified and
                                                        dedicated people are not always the ones occupy-
                                                        ing key positions.As a result, it is difficult to main-
                                                        tain continuity in the planning and delivery of pro-
                                                        grammes and there are many delays and inefficien-
                                                        cies due the constant need to bring new people
Lack of capacity Lack of financial resources and        “up to speed.”
consequent lack of well-qualified human resour-
ces, facilities, equipment and supplies mean that       => Quick and smart planning Lesotho’s Quick
most people are receiving far less than the basic          and Smart approach to planning holds the pro-
health, education and other services promised in           mise of becoming a highly effective way of
international agreements that have been ratified           assessing needs and priorities on the front lines
by donor countries and developing countries.               of the epidemic, in the communities where
                                                           people needing services live. It is easy to
=> Making do with what is available                        understand by everyone, so there is no steep
   Many stakeholders in Lesotho,Tanzania and               learning curve for novices, and it is time-cons-
   Mpumalanga have recognized that, given cons-            trained, so most key people that are there at
   traints imposed by their limited resources, the         the beginning of the planning process will still
   best course of action is to look for local solu-        be there at the end of it.
   tions that rely less on fully-qualified professio-
   nals and on facilities, equipment and supplies       => Grounding the response in communities
   of the highest standards.With technical sup-            In general, the population of small rural com-
   port, trained paraprofessionals and volunteers          munities is fairly stable and so is the leaders-
   can provide many of the services that might             hip.While people may come and go from elec-
   otherwise be provided by professionals and              ted councils, they nevertheless remain in their
   can do so using the most basic of facilities,           communities and tend to serve in other capaci-
   equipment and supplies. In the health sector,           ties, perhaps as leaders of community-based
   for example, they can deliver Voluntary                 organizations that provide services.When the
   Counselling and Testing (VCT) door to door or           response to AIDS is planned from the commu-
   in almost any kind of local centre, including a         nity up and much of the implementation ulti-
   school, and they can also deliver care, monito-         mately consists of service delivery within those
   ring patients’ use of prescribed medicines and          same communities, then there is less need to
   helping keep them healthy and resistant to              worry about high turn-over and lack of conti-
   infection by ensuring they are well nourished.          nuity at higher levels of government.

     Fear, stigma and discrimination At the work-            Learning but adapting
     shops in Lesotho,Tanzania and Mpumalanga, even          Lesotho,Tanzania and Mpumalanga Province are
     counsellors in community-based VCT programmes           all part of the Southern African Development
     and “focal persons” on HIV and AIDS in govern-          Community (SADC) and yet they are very different
     ment ministries spoke of their fear of getting          places, each with its unique governmental structu-
     tested for HIV, being exposed by failures to keep       res, cultural traditions, socio-economic conditions,
     the results confidential and being subject to stig-     and patterns of HIV and AIDS. Clearly, there is no
     ma and discrimination. Often, too, there was much       one-size-fits-all way of responding to AIDS that
     discomfort about the whole subject of HIV and           would work for all three countries but, through
     AIDS and the sexual attitudes and behaviours that       SADC and other African and international organiza-
     can result in transmission.This discomfort someti-      tions, they collaborate on their responses and
     mes made it difficult to engage in open discus-         learn from each other’s experiences.
     sions and to seek practical solutions to the pro-            This publication summarizes how the three
     blems of delivering prevention, treatment and care      countries have developed decentralized responses
     and impact mitigation – problems that often tou-        to AIDS.The accompanying Toolbox contains seve-
     ched on the issues of gender equity, women’s            ral of the essential tools they have used in plan-
     empowerment and the rights of children, inclu-          ning and implementing their response. It is unlike-
     ding orphans.                                           ly that the partners against AIDS in any other
                                                             country would be able or even want to follow
     => Getting to the roots Fear, stigma and discri-        their examples exactly or use their specific tools,
        mination are highly personal and, at the same        as is, but GTZ sincerely hopes the partners in
        time, very social.They are tied to the traditions,   other countries will find their examples and tools
        cultural values, religious beliefs, and popular      useful as they plan and implement their own
        attitudes found in any particular community.         decentralized response to AIDS.
        The community’s chiefs, elders, traditional hea-
        lers, faith-leaders, and natural opinion leaders
        (people whose personal qualities command
        respect) may contribute to fear, stigma and
        discrimination but that means they are also
        well-placed to counter the same phenomena.
        Programmes of information, education, dialo-
        gue, and debate are best designed and delive-
        red at the community level, in close collabora-
        tion with the people already mentioned and
        with women, men and youth.That way, they
        can get at the roots of fear, stigma and discrimi-
        nation and proceed to root them out.


Fulgence, B (2004). Council AIDS Multisectoral        UNAIDS/UNDP/WB (2006):“Mainstreaming AIDS
Committees’ Capacity Building: Report of the          in Development:Why and How to Do It”
Planning Meeting Held on July 23rd 2004 at Kibaha.    United Nations (2000). United Nations Millennium
Dar es Salaam,Tanzania Commission for AIDS,           Declaration: United Nations General Assembly,
Deutsche Gesellschaft für Technische Zusammenarbeit   55th session, 6 September 2000. New York:
(GTZ) GmbH, evaplan/University of Heidelberg.         United Nations.

GTZ (2005). Comprehensive Toolkit:                    United Nations (2001). Declaration of
“Mainstreaming HIV/AIDS: How we do it.” (DVD).        Commitment on HIV/AIDS: United Nations
Eschborn, Deutsche Gesellschaft für Technische        General Assembly, special session on HIV/AIDS,
Zusammenarbeit (GTZ) GmbH.                            25-27 June 2001. New York, United Nations.

HRSC (2005). South African National HIV               United Nations (2005 ). 2005 World Summit
Prevalence, HIV Incidence, Behaviour and              Outcome. New York, United Nations.
Communication Survey. Johannesburg, Nelson
Mandela Foundation (NMF) and Human Sciences           United Nations (2005).World Population
Research Council (HSRC) of South Africa.              Prospects:The 2004 Revision. New York, United
                                                      Nations Department of Economic and Social
Kimaryo, S et al, Editors (2004).Turning a Crisis     Affairs, Population Division.
into an Opportunity: Strategies for Scaling Up the
National Response to the HIV/AIDS Pandemic in         WHO (2006). Progress Report on Global Access to
Lesotho.A Publication of the Partnership of the       HIV Antiretroviral Therapy:A Report on “3 by 5”
Government of Lesotho and the Expanded Theme          and Beyond. Geneva,World Health Organization.
Group on HIV/AIDS, Lesotho. New Rochelle,
New York,Third Press Publishers.
                                                      Government of Lesotho, Health Services
National AIDS Commission Tanzania (2005).
2003-04 Tanzania HIV/AIDS indicator survey
2003–2004. March. Dar es Salaam and Calverton,        Government of South Africa, Partnership
Tanzania Commission for AIDS, National Bureau         against AIDS
of Statistics, ORC Macro.                   

UNAIDS (2006). 2006 Report on the global AIDS         GTZ, Support for the global HIV and AIDS
epidemic. Geneva, Joint United Nations
Programme on HIV/AIDS.

UNAIDS (2006). 2006 Report on the global AIDS         South African Department of Health, National
epidemic. Geneva, Joint United Nations                HIV/AIDS and Treatment Unit
Programme on HIV/AIDS.                      

UNDP, UNAIDS,World Bank (2005). Mainstreaming         Southern African Development Community,
                                                      HIV and AIDS Programme
HIV and AIDS in sectors and programmes: an
implementation guide for National responses. New      (See link at bottom of menu on left)
York, Geneva,Washington, Joint United Nations
Programme on HIV/AIDS, United Nations                 Tanzania Commission for AIDS (TACAIDS)
Development Programme and World Bank.       
     AIDS     Aquired Immune Deficiency                 NGO         Non Government Organisation
              Syndrome                                  NMF         Nelson Mandela Fund
     AMICAALL Alliance of Mayors and Municipal          PCMT        Prevention of mother-to-child
              Leaders on HIV/AIDS in Africa                         transmission
     BACKUP   Building Alliances Creating               PO          President’s Office
              Knowledge Updating Partners               RLAG        Regional Administration/Local
     CARE     Cooperative for Assistance and Relief                 Government’s division
              Everywhere                                SADC        Southern African Development
     CHAC     Council HIV and AIDS Coordinators                     Community
     CMAC     Council Multisectoral AIDS                SANAC       South African National AIDS Council
              Committee                                 STI         Sexuallly Transmitted Infection
     CSO      Civil Society Organisations               TACAIDS     Tanzania Commission for AIDS
     DED      Deutscher Entwicklungs Dienst             TANESA      Tanzania Netherlands Project to
     DHSS     Department of Health and Social                       Support AIDS control in the Mwanza
              Services                                              Region
     DVD      Digital Versatile Disc                    UN          United Nations
     GDP      Gross Domestic Product                    UNAIDS      United Nations Programme on HIV/AIDS
     GTZ      Deutsche Gesellschaft für Technische      UNDP        United Nations Development
              Zusammenarbeit                                        Programme
     HBC      Home Based Care                           UNESCO      United NationsEducational, Scientific
     HIV      Human Immundeficiency Virus                           and Cultural Organisation
     ILO      International Labour Organisations        UNFPA       United Nations Population Fund
     KaTseFA  Karolelano ea Tsebo Facilitator’s         UNHCR       United Nations High Commission for
              Association                                           Refugees
     LAPCA    Lesotho AIDS Programme                    UNICEF      United Nations Children’s Fund
              Coordinating Authority                    VCT         Voluntary Counselling and Testing
     MRDP     Mpumalanga Rural Development              WHO         World Health Organisation
              Programme                                 WMAC        Ward Multisectoral AIDS Committee

     Published by:                                      Contact
     Deutsche Gesellschaft für                          GTZ HIV Peer Review Group
     Technische Zusammenarbeit (GTZ) GmbH               E
     Dag-Hammerskjöld-Weg 1-5
     65760 Eschborn, Germany                            Writer
     T +49 (0) 61 96 79 - 0                             Stuart Adams
     F +49 (0) 61 96 79 - 1115
                                                        Contributing GTZ experts and consultants
                                                        For Lesotho: Silvio Decurtins and Kirsten Roettcher
     Health, Education and Social Protection Division   For Tanzania: Birgitte Jordan-Harder and Michael
     Supra-regional Project “AIDS Control in            Marx (evaplan Ltd.)
     Developing Countries” (PN 2003.2146.3)             For Mpumalanga: Julia Weinand
     T (+49) 6196-79- 1535
     F (+49) 6196-79-7418
                                                        The GTZ Peer Review Group Secretariat
     I                                  Photographs
                                                        Stefan Emmel, Regina Görgen, Kirsten Roettcher,
     Contact Person in the Federal Ministry for         Jacqueline Saaiman,Ahmed Twaha, Julia Weinand
     Economic Cooperation and Development (BMZ)
     Dr. Jochen Böhmer, Section 311
                                                        Design and Production
     T (+49) 1888 535-3697
                                                        design werk,Wiesbaden, Germany

                                                        Eschborn, July 2006
(contained in the toolbox section of the CD-ROM)

For Lesotho:
• Community Council Action Plan. A template for use by any Community Council.
• Guidebook for Quick and Smart Community Council Planning.
• Lipitso Information Collection Kit: to assist Community Councillors to collect community priorities.

For Tanzania:
10 Training Manuals for HIV/AIDS Committees at Local Government Authorities

For Mpumalanga Province:
A series of 9 fact sheets for Mainstreaming
a response to HIV and AIDS with local and provincial governments

  The Deutsche Gesellschaft für Technische
  Zusammenarbeit (GTZ) GmbH is a government-
  owned corporation for international cooperation
  with worldwide operations. GTZ’s aim is to posi-
  tively shape the political, economic, ecological
  and social development in our partner countries,
  thereby improving people’s living conditions and
  prospects. Through the services it provides,
  GTZ supports complex development and reform
  processes and contributes to global sustainable

Deutsche Gesellschaft
für Technische Zusammenarbeit (GTZ) GmbH

Supra-regional Project “AIDS Control in Developing Countries”
Postfach 5180
65726 Eschborn, Germany
T +49-(0)-6196-79-1535
F +49-(0)-6196-79-7418

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